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Are There Changes in the Fatty Acid Profile of Breast Milk with Supplementation of Omega-3 Sources? A Systematic Review

Existem mudanças no perfil de ácidos graxos no leite materno com a suplementação de fontes de ômega 3? Uma revisão sistemática

Abstract

Purpose

To evaluate the effect of supplementation with omega-3 sources on the fatty acid composition of human milk.

Methods

The review consisted of the search for articles published in PubMed, Biblioteca Virtual de Saúde (Virtual Health Library[VHL]) andWeb of Science databases using the following keywords: fatty acids, omega-3, human milk and supplementation; for this purpose, we have used the program of research to integrate the services for the maintenance of autonomy (PRISMA) checklist. The following selection criteria were used: articles in English, Portuguese, Spanish or Italian, published between 2000 and 2015, and about studies performed in humans. We found 710 articles that met the established criteria; however, only 22 of them were selected to be part of this study.

Results

All studies found a positive relationship between the consumption of omega- 3 sources and their concentration in humanmilk. The differences in the findings are due to the distinct methods used, such as the specific time of the omega-3 supplementation, the type of omega-3 source offered, as well as the sample size.

Conclusion

Although the studies were different in several methodological aspects, it was possible to observe the importance of omega-3 supplementation during gestation and/or the puerperium.

Keywords:
pregnant women; breastfeeding; human milk; omega-3 fatty acids; systematic review

Resumo

Objetivo

Avaliar o efeito da suplementação com fontes de ômega 3 sobre a composição de ácidos graxos do leite humano.

Métodos

A revisão consistiu na busca de artigos publicados nas bases de dados PubMed, Biblioteca Virtual de Saúde e Web of Science utilizando-se as palavras-chave: ácidos graxos, ômega-3, leitematerno e suplementação; para isso, foi utilizado o checklist PRISMA. Foram utilizados os seguintes critérios para a seleção: artigos publicados em inglês, português, espanhol ou italiano, entre os anos de 2000 a 2015, sobre estudos realizados em humanos. A busca bibliográfica, segundo a estratégia estabelecida, resultou em 710 artigos. Entretanto, apenas 22 destes foram selecionados para compor a presente revisão.

Resultados

Todos os estudos encontraram relação positiva entre o consumo de fontes de ômega 3 e sua concentração no leite humano. As diferenças nos achados se devem aos métodos empregados como, por exemplo, o momento da suplementação do ômega 3, o tipo de fonte de ômega 3 ofertado, e o tamanho amostral.

Conclusão

Apesar de os estudos serem díspares em inúmeros aspectos metodológicos, observou-se a importância da suplementação do ômega 3 na gestação e/ou no puerpério.

Palavras-chave:
gestantes; aleitamento materno; leite humano; ácidos graxos ômega-3; revisão sistemática

Introduction

The importance of polyunsaturated fatty acids of the omega-3 (ω-3) series (docosahexaenoic acid [22:6 ω3, DHA] and eicosapentaenoic acid [20:5 ω3, EPA]) in the development of the fetal brain, as well as in the cognitive and visual acuity of the child, is widely recognized. These fatty acids are part of the composition of the cell membranes and the nervous system, especially DHA, which is preferentially transported by the placenta to the fetus and provides important components to the phospholipid membrane.11. Gaete GM, Atalah SE. Niveles de LC-PUFA n-3 en la leche materna después de incentivar el consumo de alimentosmarinos. Rev Chil Pediatr 2003;74(02):158-165 22. Bortolozo EAFQ, Sauer E, Santos MS, et al. Supplementation with the omega-3 docosahexaenoic acid: influence on the lipid composition and fatty acid profile of HM. Rev Nutr 2013;26(01): 27-36

The amount of fatty acids in human milk (HM) depends on maternal stocks, dietary intake and synthesis thereof in the mammary glands.33. Ballard O, Morrow AL. Human milk composition: nutrients and bioactive factors. Pediatr Clin North Am 2013;60(01):49-74 The concentration of DHA varies specifically, probably due to the woman's feeding habits, since its synthesis in the mammary gland is minimal.11. Gaete GM, Atalah SE. Niveles de LC-PUFA n-3 en la leche materna después de incentivar el consumo de alimentosmarinos. Rev Chil Pediatr 2003;74(02):158-165 22. Bortolozo EAFQ, Sauer E, Santos MS, et al. Supplementation with the omega-3 docosahexaenoic acid: influence on the lipid composition and fatty acid profile of HM. Rev Nutr 2013;26(01): 27-36 44. Nishimura RY, Barbieiri P, Castro GS, Jordão AA Jr, Perdoná GdaS, Sartorelli DS. Dietary polyunsaturated fatty acid intake during late pregnancy affects fatty acid composition of mature breast milk. Nutrition 2014;30(06):685-689 During gestation and lactation, this synthesis is limited by the fetus. For this reason, numerous studies have been conducted to evaluate the effects of the supplementation of this fatty acid on the composition of HM .44. Nishimura RY, Barbieiri P, Castro GS, Jordão AA Jr, Perdoná GdaS, Sartorelli DS. Dietary polyunsaturated fatty acid intake during late pregnancy affects fatty acid composition of mature breast milk. Nutrition 2014;30(06):685-689 55. Atalah SE, Araya BM, Rosselot PG, et al. Consumption of a DHAenriched milk drink by pregnant and lactating women, on the fatty acid composition of red blood cells, breast milk, and in the newborn. Arch Latinoam Nutr 2009;59(03):271-277 Other facts to be taken into consideration are that the concentration of DHA in HM decreases as lactation progresses, and that supplementation during lactation raises DHA concentrations in breast milk.66. Innis SM. Human milk: maternal dietary lipids and infant development. Proc Nutr Soc 2007;66(03):397-404

The study conducted by Bortolozo et al (2013)22. Bortolozo EAFQ, Sauer E, Santos MS, et al. Supplementation with the omega-3 docosahexaenoic acid: influence on the lipid composition and fatty acid profile of HM. Rev Nutr 2013;26(01): 27-36 aimed to evaluate the impact of omega-3 fatty acid supplementation between the third trimester of pregnancy and the third month after delivery, and its influence on the composition of HM. Although no statistical difference was found in the total lipid values between the studied groups, the milk of mothers supplemented with fish oil had higher concentrations of DHA and EPA, demonstrating that a higher consumption of omega-3 may influence its concentration in HM.22. Bortolozo EAFQ, Sauer E, Santos MS, et al. Supplementation with the omega-3 docosahexaenoic acid: influence on the lipid composition and fatty acid profile of HM. Rev Nutr 2013;26(01): 27-36 However, the results on the effects of omega-3 supplementation during gestation are still contradictory.44. Nishimura RY, Barbieiri P, Castro GS, Jordão AA Jr, Perdoná GdaS, Sartorelli DS. Dietary polyunsaturated fatty acid intake during late pregnancy affects fatty acid composition of mature breast milk. Nutrition 2014;30(06):685-689

Due to the controversies between the studies, as well as to the importance of the theme for the health of the newborn, this systematic review aims to evaluate the studies that verified the effects of omega-3 supplementation during pregnancy and/or the puerperium on the composition of HM. The bibliographical survey of this theme aims to assist the maternal and infant populations, together with health professionals, to determine the importance of supplementation, offering subsidies for its practice.

Methods

A systematic review of the available literature consisted of a retrospective search of scientific articles that aimed to evaluate the composition of HM after supplementation with omega-3 fatty acids.

The following bibliographic databases have been used: PubMed, Biblioteca Virtual da Saúde (Virtual Health Library [VHL]) and Web of Science. The search for the articles was performed independently by two researchers, and it began in August and ended in October of 2015. The selected studies were published during the period comprised between 2000 and 2015. The following keywords were used in the search strategy: fatty acids, omega-3, human milk and supplementation.

The bibliographic search was performed according to the established strategy, and resulted in 710 articles. A total of 163 articles were found in the VHL database; however, after reading the abstracts, we have selected 11 thereof; 239 articles were found in the PubMed database; however, we have only selected 21of these; and 308 articles were found in the Web of Science database, from which we have selected 2 articles. Thus, a total of 22 articles have been selected to compose the present study, reiterating that there were 12 articles replicated in the analyzed databases. The others were suppressed for the following reasons: discussion of different associations between omega-3 and HM, such as allergy, visual acuity and growth; literature reviews; studies replicated across different databases; studies published in other languages and/or that were were not available in their entirety. We used a checklist with 27 items and a 4-step flowchart, advocated by PRISMA,77. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. LoS Med 2009;6(07):e1000097 which aims to help authors improve the reporting of systematic reviews. Therefore, a summary of each stage of the selection process of articles that composed this systematic review was arranged in the Flowchart (Fig. 1).

Fig. 1
Flowchart of the selection process for selected articles – PRISMA.

The criteria used in the selection of articles for the review included language (Portuguese, English, Spanish and Italian) and year of publication (2000 to 2015).

The selected articles were compared in relation to the following parameters: year of publication, country of origin, sample size, average age of participants, type of design, rate of follow-up losses, period in which the woman and the milk have been evaluated, omega-3 supplementation period, type of supplement, amount offered, omega-3 evaluation methods, confounding factors controlled in the analysis, estimators used in the statistical analysis, and main results observed.

Results

Once the established strategy was put into practice, 22 articles were selected by bibliographic search to compose the present revision. Four were originated in the United States, one in Canada, one in Denmark, three in Brazil, three in Australia, three in Chile, one in Israel, one in Iceland, one in Mexico, two in Germany, and two in the Netherlands. Regarding the age groups, the majority of the articles (18) only reported the average age of the participants. Regarding language, two articles were written in Spanish, one in Portuguese and the remaining ones in English (Table 1).

Table 1
Year of publication, origin, sample size, and age of the participants of the selected studies on the fatty acid profile of breast milk with the supplementation of omega-3 sources, 2000–2015

As for the design employed, intervention studies were used in most cases, and there was only one observational study. Information on follow-up losses were obtained from 21 studies. The losses ranged from 0 to 78%. The results among the studies, regarding the period of evaluation of the woman and the milk, were quite dissimilar. Regarding the period of supplementation, it was observed that 12 studies evaluated supplementation in infants, 7 in pregnant women, and only 3 evaluated supplementation both in pregnancy and in the puerperium (Table 2).

Table 2
Type of design, losses, period of evaluation and supplementation of sources of omega-3, 2000–2015

In regards to the type of supplement or food offered to the participants, 3 studies used dairy supplements, 16 provided DHA-rich oils (such as, tuna, single-celled algae, cod, flaxseed), 2 supplied fish (sardine and jure) and 1 study performed food education to increase the consumption of fish sources. As for the method to evaluate the amount of omega 3 in HM, it was observed that all the studies used chromatography. The DHA value ranged from 170 mg to 2,200 mg per day (Table 3).

Table 3
Characteristics of the selected studies on the profile of fatty acids in breast milk with omega-3 sources supplementation, 2000–2015

Among the 22 selected articles, 9 did not evaluate the consumption of omega-3 food sources. Among those who reported it, the majority (32%) used the food frequency questionnaire (FFQ). Regarding the estimators, it was observed that nine studies used the average, seven used the correlation index, five the median and only one study used the combination of correlation index with the average. Regarding the exclusion criteria, nine articles did not mention them in the methods (Table 4).

Table 4
Controlled confounding factors, eligibility and exclusion criteria and main results found between supplementation of omega-3 sources on the fatty acid composition of human milk, 2000–2015

Regarding supplementation, all studies found a positive relationship between the consumption of omega-3 sources and their concentration in HM, therefore, highlighting the importance of supplementation of these fatty acids during pregnancy and/or puerperium, which translates into positive results in both cognitive development and visual acuity.

Discussion

The omega-3 and omega-6 polyunsaturated fatty acids consumed through dietary triglycerides are digested in the small intestines and can then be absorbed, transported into the bloodstream and taken up between tissues throughout the body (including brain, retina and heart).88. Williams CM, Burdge G. Long-chain n-3 PUFA: plant v. marine sources. Proc Nutr Soc 2006;65(01):42-50 Essential dietary fatty acids in the form of linoleic acids (LAs) and α − linolenic acids (ALAs) are activated in the forms known as keto-acyl-CoA, and then used for the conversion of long chain polyunsaturated fatty acids and other polyunsaturated products, such as those derived from the series of desaturation and elongation reactions that are particularly active in the liver and, to a lesser extent, in other tissues.88. Williams CM, Burdge G. Long-chain n-3 PUFA: plant v. marine sources. Proc Nutr Soc 2006;65(01):42-50

Linoleic and ALA fatty acids need to be ingested through food, since the human body does not have enzymes to synthesize them. Some vegetables synthesize them and are, therefore, an abundant source of these fatty acids, as well as the products derived from these vegetables. Omega-3 fatty acids (DHA and EPA) can be synthesized by the human body to a certain level, albeit a very limited one. The consumption of omega-3 sources through diet can be done by ingesting fish or fish oils, and foods enriched or fortified with these important fatty acids.99. Holub BJ. Clinical nutrition: 4. Omega-3 fatty acids in cardiovascular care. CMAJ 2002;166(05):608-615

Although ALA in humans is converted to EPA and DHA, the exact percentage of this conversion is unknown, but it is estimated to be low (5% EPA and 0.5% DHA).1010. Burdge GC. Metabolism of alpha-linolenic acid in humans. Prostaglandins Leukot Essent Fatty Acids 2006;75(03):161-168 1111. Kus MM, Mancini-Filho J. Ácidos graxos: eicosapentaenóico (EPA) e docosahexaenóico (DHA). São Paulo: ILSI Brasil; 2010 Due to their enzymatic immaturity, children and especially neonates cannot convert all the DHA required for their development from ALA.1212. Agostoni C. Role of long-chain polyunsaturated fatty acids in the first year of life. J Pediatr Gastroenterol Nutr 2008;47(Suppl 2): S41-S44 Therefore, feeding in the gestational period is of great importance as it determines the type of fatty acid that will accumulate in the fetal tissue. The essential fatty acids are transferred through the placenta, and in the third gestational trimester are deposited in the brain and retina of the fetus. It should be noted that the fetus withdraws a total of 50 to 75mg of polyunsaturated fatty acids from the mother, most of them being DHA.1313. Imhoff-Kunsch B, Stein AD, Martorell R, Parra-Cabrera S, Romieu I, Ramakrishnan U. Prenatal docosahexaenoic acid supplementation and infantmorbidity: randomized controlled trial. Pediatrics 2011;128(03):e505-e512 1414. Carlson SE, Colombo J, Gajewski BJ, et al. DHA supplementation and pregnancy outcomes. Am J Clin Nutr 2013;97(04):808-815 1515. Rogers LK, Valentine CJ, Keim SA. DHA supplementation: current implications in pregnancy and childhood. Pharmacol Res 2013; 70(01):13-19 1616. Swanson D, Block R,Mousa SA. Omega-3 fatty acids EPA and DHA: health benefits throughout life. Adv Nutr 2012;3(01):1-7

Numerous studies have been conducted to evaluate the effects of the supplementation of omega-3 and its metabolites in pregnancy and puerperium on the composition of HM. This is due to the synthesis of DHA probably occurring minimally in the mammary gland66. Innis SM. Human milk: maternal dietary lipids and infant development. Proc Nutr Soc 2007;66(03):397-404 1717. Fidler N, Sauerwald T, Pohl A, Demmelmair H, Koletzko B. Docosahexaenoic acid transfer into human milk after dietary supplementation: a randomized clinical trial. J Lipid Res 2000; 41(09):1376-1383 1818. Jensen CL, Maude M, Anderson RE, Heird WC. Effect of docosahexaenoic acid supplementation of lactating women on the fatty acid composition of breast milk lipids and maternal and infant plasma phospholipids. Am J Clin Nutr 2000;71(1, Suppl):292S-299S as well as due to the role that this polyunsaturated fatty acid plays on visual acuity, cognition and in the formation of the nervous tissue of the newborn.1919. Makrides M. Outcomes for mothers and their babies: do n-3 longchain polyunsaturated fatty acids and seafoods make a difference? J Am Diet Assoc 2008;108(10):1622-1626

Although supplementation appears to be the most reliable medium for increasing omega-3 levels in HM, there are numerous differences among the studies evaluated in relation to the following parameters: sample size, study design, timing of omega-3 supplementation (gestation and/or lactation), type of supplementation (fish oil, in natura fish consumption), and amount and type of omega-3 offered (EPA and/or DHA).

Regarding the diversity of the countries where the studies selected for this systematic review were performed, it is worth noting that the consumption of omega-3 rich foods in Western countries is well below that of other countries.2020. Dunstan JA, Mitoulas LR, Dixon G, et al. The effects of fish oil supplementation in pregnancy on breast milk fatty acid composition over the course of lactation: a randomized controlled trial. Pediatr Res 2007;62(06):689-694 In the United States, the intake of omega-3 and its metabolites (DHA and EPA) was estimated at 1.6 and 0.1–0.2 g/day respectively, and the dietary ratio between omega-6 and omega-3 was ≈ 9.8:1.2121. Kris-Etherton PM, Taylor DS, Yu-Poth S, et al. Polyunsaturated fatty acids in the food chain in the United States. Am J Clin Nutr 2000;71(1, Suppl)179S-188S A study with Canadian pregnant women showed that the average daily intake of omega-3 and DHA was 1.45 and 0.082 g/day respectively.2222. Denomme J, Stark KD, Holub BJ. Directly quantitated dietary (n-3) fatty acid intakes of pregnant Canadian women are lower than current dietary recommendations. J Nutr 2005;135(02):206-211 Populations living in coastal countries, such as Japan and Norway, where fish are widely consumed, have a higher dietary intake of omega-3 (>1 g/day), and consequently, high concentrations of DHA in their breast milk.2020. Dunstan JA, Mitoulas LR, Dixon G, et al. The effects of fish oil supplementation in pregnancy on breast milk fatty acid composition over the course of lactation: a randomized controlled trial. Pediatr Res 2007;62(06):689-694 2323. Hibbeln JR, Nieminen LR, Blasbalg TL, Riggs JA, Lands WE. Healthy intakes of n-3 and n-6 fatty acids: estimations considering worldwide diversity. Am J Clin Nutr 2006;83(6, Suppl)1483S-1493S 2424. Brenna JT, Varamini B, Jensen RG, Diersen-Schade DA, Boettcher JA, Arterburn LM. Docosahexaenoic and arachidonic acid concentrations in human breast milk worldwide. Am J Clin Nutr 2007;85(06):1457-1464 Although there is no official dietary recommendation for EPA and DHA in the US, several expert groups suggest a DHA intake of at least 200 mg/day, which may reach 1,000 mg DHA/day for pregnant and lactating women, and 1.4–2.7 g of omega-3, and suggest the omega-6/omega-3 ratio of ≈ 2–5:1.2121. Kris-Etherton PM, Taylor DS, Yu-Poth S, et al. Polyunsaturated fatty acids in the food chain in the United States. Am J Clin Nutr 2000;71(1, Suppl)179S-188S 2525. Koletzko B, Lien E, Agostoni C, et al;World Association of Perinatal Medicine Dietary Guidelines Working Group. The roles of longchain polyunsaturated fatty acids in pregnancy, lactation and infancy: review of current knowledge and consensus recommendations. J Perinat Med 2008;36(01):5-14

Corroborating the above recommendations, the consensus published by Koletzko et al2626. Koletzko B, Cetin I, Brenna JT; Perinatal Lipid Intake Working Group; Child Health Foundation; Diabetic Pregnancy Study Group; European Association of Perinatal Medicine; European Association of Perinatal Medicine; European Society for Clinical Nutrition and Metabolism; European Society for Paediatric Gastroenterology, Hepatology and Nutrition, Committee on Nutrition; International Federation of Placenta Associations; International Society for the Study of Fatty Acids and Lipids. Dietary fat intakes for pregnant and lactating women. Br J Nutr 2007;98(05):873-877 states that an average intake of at least 200 mg of DHA per day is advisable; it also states that consumption of up to 1 g of DHA or 2 to 7 g of omega-3 per day is safe. This amount can be achieved by consuming one to two servings of fish per week, including fatty fish such as herring, mackerel and salmon. However, it is known that the consumption of fish can contribute significantly to the exposure to contaminants such as methylmercury, which is particularly toxic to the developing brain and possibly harmful to infant growth. To decrease the amounts of methylmercury in the body, one should reduce the intake of contaminated foods during the pregestational and gestational periods. The fish with the highest levels of methylmercury are predatory fish such as marlin, pike, swordfish and shark. However, after an extensive literature review, the consensus points out that the beneficial effects of regular consumption of fish sources of DHA during pregnancy appear to overcome the potential drawbacks of the increased intake of contaminants.

Regarding the period of supplementation, the selected studies presented different time periods (pregnant and/or nursing) when omega-3 supplementation was performed and measured, which may partially justify the differences in the results we found. On this issue, in their randomized clinical trial, Boris et al2727. Boris J, Jensen B, Salvig JD, Secher NJ, Olsen SF. A randomized controlled trial of the effect of fish oil supplementation in late pregnancy and early lactation on the n-3 fatty acid content in human breast milk. Lipids 2004;39(12):1191-1196 evaluated two hypotheses, namely: 1) whether omega-3 supplementation during pregnancy increased omega-3 levels at the beginning of breastfeeding; and 2) whether the continuation of supplementation after delivery was necessary to sustain the long-term increase in omega-3 levels. There was a marked drop in omega-3 levels in the group that stopped supplementation during the puerperium. Such a decrease in the concentration of DHA in breast milk as lactation progresses is corroborated by numerous studies.44. Nishimura RY, Barbieiri P, Castro GS, Jordão AA Jr, Perdoná GdaS, Sartorelli DS. Dietary polyunsaturated fatty acid intake during late pregnancy affects fatty acid composition of mature breast milk. Nutrition 2014;30(06):685-689 2828. Makrides M, Gibson RA. Long-chain polyunsaturated fatty acid requirements during pregnancy and lactation. Am J Clin Nutr 2000;71(1, Suppl)307S-311S 2929. Bonham MP, Duffy EM, Wallace JM, et al. Habitual fish consumption does not prevent a decrease in LCPUFA status in pregnant women (the Seychelles Child Development Nutrition Study). Prostaglandins Leukot Essent Fatty Acids 2008;78(06): 343-350 On the other hand, the group that received fish oil during gestation and lactation showed levels of omega-3 three times higher, and double the levels of DHA.2727. Boris J, Jensen B, Salvig JD, Secher NJ, Olsen SF. A randomized controlled trial of the effect of fish oil supplementation in late pregnancy and early lactation on the n-3 fatty acid content in human breast milk. Lipids 2004;39(12):1191-1196 It is worth mentioning that polyunsaturated fatty acids are deposited in the brain during the last gestational trimester, and that this process continues after delivery. Furthermore, the neurological development continues during the first years of life.2727. Boris J, Jensen B, Salvig JD, Secher NJ, Olsen SF. A randomized controlled trial of the effect of fish oil supplementation in late pregnancy and early lactation on the n-3 fatty acid content in human breast milk. Lipids 2004;39(12):1191-1196 The results found by Ribeiro et al3030. Ribeiro P, Carvalho FD, Abreu AdeA, Sant'anna MdeT, Lima RJ, Carvalho PdeO. Effect of fish oil supplementation in pregnancy on the fatty acid composition of erythrocyte phospholipids and breast milk lipids. Int J Food Sci Nutr 2012;63(01):36-40 also demonstrated that supplementation with fish oil limited to pregnancy was not as effective as supplementation during pregnancy and lactation. Therefore, supplementation during pregnancy and lactation is recommended by numerous studies.2020. Dunstan JA, Mitoulas LR, Dixon G, et al. The effects of fish oil supplementation in pregnancy on breast milk fatty acid composition over the course of lactation: a randomized controlled trial. Pediatr Res 2007;62(06):689-694 3030. Ribeiro P, Carvalho FD, Abreu AdeA, Sant'anna MdeT, Lima RJ, Carvalho PdeO. Effect of fish oil supplementation in pregnancy on the fatty acid composition of erythrocyte phospholipids and breast milk lipids. Int J Food Sci Nutr 2012;63(01):36-40 3131. Gaete MG, Atalah ES, Araya JA. Efecto de la suplementación de la dieta de la madre durante la lactancia con ácidos grasos omega 3 en la composición de los lípidos de la leche. Rev Chil Pediatr 2002; 73(03):239-247

Important issues to take into account in these studies are the type of omega-3 source and the quantity that was supplied. It was observed that most of the selected studies used fish oil to increase the consumption of omega-3; however, some studies have used the supply of fresh food, fortified drinks and food education techniques. The use of fish oil has benefits, but it can lead to low compliance due to its adverse effects, such as fish flavor eructation, digestive discomfort and night sweats.55. Atalah SE, Araya BM, Rosselot PG, et al. Consumption of a DHAenriched milk drink by pregnant and lactating women, on the fatty acid composition of red blood cells, breast milk, and in the newborn. Arch Latinoam Nutr 2009;59(03):271-277 3232. Marc I, Plourde M, Lucas M, et al. Early docosahexaenoic acid supplementation of mothers during lactation leads to high plasma concentrations in very preterm infants. J Nutr 2011; 141(02):231-236 The randomized double blind clinical trial conducted by Dunstan et al2020. Dunstan JA, Mitoulas LR, Dixon G, et al. The effects of fish oil supplementation in pregnancy on breast milk fatty acid composition over the course of lactation: a randomized controlled trial. Pediatr Res 2007;62(06):689-694 aimed to evaluate the effects of fish oil supplementation during pregnancy on the composition of HM and on the development of the infant in the first year of life. The concentration of fatty acids in the milk was analyzed on the third day, sixth week and sixth month after delivery. It was observed that women who received fish oil had a higher concentration of EPA and DHA in the milk on the third day and the sixth week after delivery.

Regarding the consumption of fish, the study by Henderson et al3333. Henderson RA, Jensen RG, Lammi-Keefe CJ, Ferris AM, Dardick KR. Effect of fish oil on the fatty acid composition of human milk and maternal and infant erythrocytes. Lipids 1992;27(11):863-869 demonstrated that ingesting 100–120 g of sardines 2 to 3 times a week resulted in increased levels of fatty acids without the need for fish oil. Harris et al3434. Harris WS, ConnorWE, Lindsey S.Will dietary omega-3 fatty acids change the composition of human milk? Am J Clin Nutr 1984; 40(04):780-785 disagreed with this, and have observed that in order to increase 0.5 to 1 g of DHA in breast milk, it is necessary to consume 350–750 g of 1% fat or 75–150 g of 10% fish fat. In the study by Patin et al,3535. Patin RV, VítoloMR, ValverdeMA, Carvalho PO, Pastore GM, Lopez FA. The influence of sardine consumption on the omega-3 fatty acid content of mature human milk. J Pediatr (Rio J) 2006;82(01): 63-69 it was observed that the levels of DHA in HM increased with the ingestion of 300 g of sardines per week, with 5% fat, without the need to use fish oil supplementation. This study recommended the consumption of fish two to three times per week during gestation.

Gaete and Atalah11. Gaete GM, Atalah SE. Niveles de LC-PUFA n-3 en la leche materna después de incentivar el consumo de alimentosmarinos. Rev Chil Pediatr 2003;74(02):158-165 conducted a prospective study with 26 pregnant women, which consisted of an educational feeding strategy to recommend individual consumption of different preparations based on marine foods. A guide with information on the importance of maternal lactation to the newborn, and on the importance of fish consumption by the mother to increase DHA levels was also distributed. The strategy of food education is considered an important intervention to raise awareness about the need for fish consumption during the gestational and puerperal period.

The study by Atalah et al55. Atalah SE, Araya BM, Rosselot PG, et al. Consumption of a DHAenriched milk drink by pregnant and lactating women, on the fatty acid composition of red blood cells, breast milk, and in the newborn. Arch Latinoam Nutr 2009;59(03):271-277 aimed to evaluate the effects of the introduction of omega-3 fortified milk beverages (DHA and EPA) during gestation on the composition of HM and red blood cells. One-hundred and seventy-five women from the intervention group and 177 from the control group were evaluated in the clinical trial. The pregnant women were evaluated at three moments of the pregnancy and once after delivery to evaluate the consumption near the date of the interview. The evaluation of milk composition was performed in only 16 women, and a 50% increase in omega-3 in breast milk was observed. However, there was no statistical difference between the evaluated groups in relation to the amount of EPA and DHA, probably due to the small sample size.

Regarding the type of omega-3 offered, seven studies offered DHA and EPA, seven offered DHA only, and three offered DHA, arachidonic acid (ARA) and EPA. It was observed that the amount of DHA was always higher than that of EPA, probably because of its important role on the nervous system, cognition and vision. It is worth noting that there is no consensus regarding the optimal levels of DHA consumption at different stages of life. However, most technical groups recommend around 200 to 500 mg/day in the adult population, and, during gestation, it is recommended to consume fish between two to three times per week.55. Atalah SE, Araya BM, Rosselot PG, et al. Consumption of a DHAenriched milk drink by pregnant and lactating women, on the fatty acid composition of red blood cells, breast milk, and in the newborn. Arch Latinoam Nutr 2009;59(03):271-277

There are numerous factors that contribute to the variability of EPA and DHA content in breast milk, such as lactation stage, gestational age, and maternal nutritional status. What is verified is that certain selected studies2020. Dunstan JA, Mitoulas LR, Dixon G, et al. The effects of fish oil supplementation in pregnancy on breast milk fatty acid composition over the course of lactation: a randomized controlled trial. Pediatr Res 2007;62(06):689-694 2727. Boris J, Jensen B, Salvig JD, Secher NJ, Olsen SF. A randomized controlled trial of the effect of fish oil supplementation in late pregnancy and early lactation on the n-3 fatty acid content in human breast milk. Lipids 2004;39(12):1191-1196 3030. Ribeiro P, Carvalho FD, Abreu AdeA, Sant'anna MdeT, Lima RJ, Carvalho PdeO. Effect of fish oil supplementation in pregnancy on the fatty acid composition of erythrocyte phospholipids and breast milk lipids. Int J Food Sci Nutr 2012;63(01):36-40 3636. Francois CA, Connor SL, Bolewicz LC, ConnorWE. Supplementing lactating women with flaxseed oil does not increase docosahexaenoic acid in their milk. Am J Clin Nutr 2003;77(01):226-233 did not control the analyses for important confounding factors, such as food consumption. Therefore, estimates of association may be compromised by the fact that certain studies did not quantify follow-up losses, but also because they did not control important confounding factors.

All selected articles showed the importance of supplementation of omega-3 in different forms (capsules, dairy drinks, strategy for feeding education, consumption of fish) on the nutritional composition of HM in the gestational and/or puerperal periods. However, four studies11. Gaete GM, Atalah SE. Niveles de LC-PUFA n-3 en la leche materna después de incentivar el consumo de alimentosmarinos. Rev Chil Pediatr 2003;74(02):158-165 55. Atalah SE, Araya BM, Rosselot PG, et al. Consumption of a DHAenriched milk drink by pregnant and lactating women, on the fatty acid composition of red blood cells, breast milk, and in the newborn. Arch Latinoam Nutr 2009;59(03):271-277 2727. Boris J, Jensen B, Salvig JD, Secher NJ, Olsen SF. A randomized controlled trial of the effect of fish oil supplementation in late pregnancy and early lactation on the n-3 fatty acid content in human breast milk. Lipids 2004;39(12):1191-1196 3737. Smit EN, Koopmann M, Boersma ER, Muskiet FA. Effect of supplementation of arachidonic acid (AA) or a combination of AA plus docosahexaenoic acid on breastmilk fatty acid composition. Prostaglandins Leukot Essent Fatty Acids 2000;62(06):335-340 did not reach statistical significance. This can be partially explained by the sample size, which can reduce the strength of the study to elucidate possible associations, possible adhesion reduction in relation to the intake of supplements and the food education practices employed, as well as the follow-up losses, which may cause a decrease in the validity of the results.

Conclusion

Although the studies were disparate in several methodological aspects, the importance of omega-3 supplementation in pregnancy and/or the puerperium, especially DHA, as well as the safety of its supplementation were observed with the data from the studies that composed this systematic review. However, it is of great importance that further studies be conducted to establish the adequate amount of omega-3s and their metabolites during gestation and lactation that will bring benefit to newborns.

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Publication Dates

  • Publication in this collection
    Mar 2017

History

  • Received
    11 Feb 2016
  • Accepted
    20 Dec 2016
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